The term, “bipolar,” implies a static and symmetrical illness where the subject flips back and forth between two sharply contrasting (and “polar” opposite) mood “episodes” or “states” that bear no seeming relation.
“Cycling” acknowledges the reality of a dynamic and not necessarily symmetrical condition where one mood “phase” gives rise to another and perhaps yet another.
In addition, cycling acknowledges the likelihood of other cycle disturbances, such as sleep.
On with the show ...
Mood Disorders
Cycling Illness (all of the below must be met):
- Evidence of a mood cycling pattern (through clinical observation, case history, or patient or witness reports), with discernible contrasting phases.
- At least one phase (or the combined effect of more than one phase) must be a significant departure from baseline condition
- At least one phase (or the the combined effect of more than one phase) must significantly impair ability to work, relate to others, and enjoy life.
Cycling I: Subject experiences one or more mood cycles from depressive low or a non-manic low to manic high.
Cycling II: Subject experiences one or more mood cycles from depressive low to hypomanic high.
Cycling III: Subject experiences one or more mood cycles from depressive low to non-depressive high.
Cyclothymia: Subject experiences one or more cycles from elements of depression to elements of hypomania.
B. Phases:
DEPRESSIVE PHASE
Subject may experience recurrent or highly recurrent or cycling depression (see My Alternative Depression Diagnosis - Part II).
MANIC PHASE (check one):
Euphoric
Subject may experience uncharacteristic feelings of extreme joy, superhuman positive abilities, and a sense of connectedness with the world, him or herself, and those around him or her. Subject may project a magnanimous “larger than life” presence.
Dysphoric
Subject may experience uncharacteristic feelings of extreme irritability, superhuman positive and negative abilities, and a sense of disconnectedness with the world, him or herself, and those around him or her. Subject may project a hostile menacing presence.
Domains (both must be checked):
Behavior:
Subject may display high energy, little need for sleep, pressured speech, a sense of impatience, an inability to control impulses, lack of judgment, and a need to satisfy cravings and indulge in projects or engage in risky behavior.
Behavior must be out of control to the point that subject can no longer responsibly manage his or her affairs or reasonably interact with others.
Thinking:
Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one’s surroundings or neglecting one’s responsibilities. On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.
Thinking must be out of control to the point where subject has a grossly distorted perception of him or herself and his or her surroundings, and is no longer capable of making realistic or responsible decisions.
Qualifying Criteria:
Mania lasts most of the day for at least two days and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).
HYPOMANIC PHASE (check one):
Euphoric
Subject may experience uncharacteristic feelings of joy, enhanced positive abilities, and a sense of ease with the world and those around him or her. Subject may project a sociable charismatic presence.
Dysphoric
Subject may experience uncharacteristic feelings of irritability, enhanced positive and negative abilities, and a sense of unease with the world, him or herself, and those around him or her. Subject may project an unpleasant mildly threatening presence.
Domains (both must be checked):
Behavior:
Subject may display high energy, little need for sleep, pressured speech, feel a need to get things done or experience pleasurable activities, and not think through the consequence of his or her actions.
Subject may exhibit unusual or unexpected behavior, but is still capable of responsibly managing his or her affairs and interacting with others.
Thinking:
Subject may experience racing thoughts, expansive thoughts, or disturbed thoughts. On one hand, subject may become easily distracted, on the other may be focused to the point of tuning out one’s surroundings or neglecting one’s responsibilities. On one hand, subject may experience a state of hyper-awareness; on the other may experience difficulties in basic cognitive tasks.
Subject may have a mildly distorted perception of him or herself and his or her surroundings, but is still capable of making realistic and responsible decisions.
Qualifying Criteria
Hypomania lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).
NON-DEPRESSIVE HIGH PHASE
Subject may simply feel “normal” or “better than normal” and not feeling depressed, but does not cycle higher into hypomania or mania. Nevertheless, “normal” or “better than normal” stands in sharp contrast to depression and points to evidence of a cycling phenomenon.
Qualifying Criteria
Non-depressive high phase lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect (other than antidepressant medications).
NON-MANIC LOW PHASE
Subject may feel “normal” or “worse than normal” and not feeling manic, but does not cycle lower into depression. Nevertheless, “normal” or “worse than normal” stands in sharp contrast to mania and points to evidence of a cycling phenomenon.
Qualifying Criteria
Non-mania low phase lasts most of the day for at least one day and is not attributable to alcohol or drug use or a medications side effect.
***
Discussion Points
There is considerable overlap between “Cycling Depression” as part of my Alternative Depression Diagnosis and “Cycling III” as part of my Alternative Bipolar (Cycling) Diagnosis. I would submit the overlap far closer resembles reality than the artificial (and out of position) categorical gap imposed by the current (and future) DSM. Nevertheless, a differentiator or two would be helpful. Perhaps evidence of bipolar in a family member for a Cycling III diagnosis?
Your views?
Also, I can use some help on hypomania. Just because it is a deviation from a subject’s baseline condition doesn’t mean it has to be regarded as a pathology. Like any phase of a cycling illness, hypomania has to be looked at in terms of what is likely to come next in the cycle. A shift from euphoric to dysphoric hypomania? A swing up to mania? A steady slide down into something approaching normal? Or a precipitous crash into depression?
My view is that clinicians tend to treat hypomania as if it were mania and thus they err on the side of over-medicating us. Your views?
***
This is a lot more to come to my alternative bipolar (cycling) diagnosis, including mixed phases, rapid cycling, and dimensional and spectrum considerations. Stay tuned. In the meantime, your feedback is strongly encouraged. Fire away ...
Further Reading from Knowledge is Necessity
Grading Bipolar - Stating What's Obvious
From BipolarConnect
The Depression-Mania Two-Step
The Depression-Mania Two-Step - Part II
What It's Really All About is Cycling
Posts
11 comments:
this is all fine and dandy John, but it ignores all previous empirical literature, and it would really lead to new incompatible literature...so crappy as the old stuff may be, they have accumulated some empirical evidence that help us to guide treatment, and other interventions. Good luck conducting field trials, and validation studies with your sub-types!
Hey, Yanni. Don't think it ignores Kraepelin. :)
Kraepelin was just the beginning of the empirical literature...I was referring really to all the studies we have accumulated over the last few decades that provide important information based on the DSM lingo...
Hi, Yanni. Here's the paradox: My starting point is "rip it up and start over." Yet I draw on the wisdom of mainstream research. I would submit that had the people who worked on the draft DSM-5 not been bound by the constraints placed on them, you would have seen a very different draft DSM-5 bipolar diagnosis.
Had each individual been allowed to come up with their own draft independently, my guess is you would have seen 10 wildly different versions.
And guess what? Each of the 10 versions would have been capable of validation. We have a number of different rating scales already for various bipolar episodes, each one scientifically validated.
Check out: http://www.psychiatrictimes.com/display/article/10168/53806?pageNumber=1
But here's the bottom line: Euphoric mania/hypomania and dysphoric mania/hypomania are well-recognized by the experts. Yet the DSM doesn't make a separation. Stupid-stupid-stupid.
Let the DSM include someone else's definition for these states - it's no skin off my nose. Just get the distinction in there.
Same with cycling. As you know, it's been around since Falret coined "folie circulaire" back in 1851. Yet, with the exception of rapid-cycling (which the DSM is very vague and in hopeless error on), the DSM makes no reference to the fact that our illness is driven by cycling. Again, use someone else's criteria - not mine. Just get the damned thing in the next DSM.
Same with the various spectrum/dimensional issues. The research is there. The DSM is ignoring it.
Do you seriously think if the people working on the draft DSM-5 had done their jobs I would have even thought of coming up with my own version? But since they made me go through all this trouble - well, I feel at liberty to adopt my own language.
Again, they are more than happy to throw out mine and use theirs. They already have it, along with the requisite validation.
In the final analysis, though, advances in brain science will render just about all our precious empirical data obsolete and the people working on the DSM-5 know this. In the meantime, though, people are being misdiagnosed right now, or else not being diagnosed to a higher level of sophistication. Our population can't afford to wait 20 years for brain science to sweep the past aside.
John, you are right on all your points, and of course you have every right to come up with your own DSM versions, as anyone else who is affected by this condition, and I think such accounts are invaluable and should be read by every clinician and researcher.
But prior to the DSM days, what we had was complete chaos, with every psychiatrist developing their own "nosology", which of course would be completely invalid. And valid or not, they would still use their personal systems (not 10 or 100 but thousands) and have their own crazy ideas about treatments that work that had no empirical evidence whatsoever - at the expense of course of the patients.
These are not things that I know only from my studies but also from personal experience growing up in Greece, and experiencing this irrational system by Greek Psychiatrists who thought that each one of them knew better than the other - at the expense of course again of patients - my father and family in this case.
The DSM has a lot of work behind it, and many people continue to work for it and with it. It may not be as good as other perhaps more advanced psychometric instruments, and it may refer to many "conditions" and "illnesses" that are nothing but science-fiction, but it does give us one commonly agreed system to work with - and as you very rightly say until the gene and brain people figure things out (if they ever do) and come up with completely different names, disorders, categories, conditions whatever. If this ever happens, I am sure they will be using terms that will refer to some gene families or brain structures or similar things that may make very little sense to most of us.
As a young researcher, I grew up with the DSM-IV, and I tend to appreciate the difficulty in undertaking such a difficult task - for something so intangible. It's not the end of the story, and of course who ever wants to do work and move things forward doesn't stick with what's in that holy "bible" but it is some progress over what it was before.
It's easy for us to lose sight of the progress we make, and to discard decades of hard work. And we tend to do that really, especially if we care a lot about the matter in question, and we want to improve things.
Last time I checked the DSM-V website, they had open ended sections and were calling for people to submit their views and constructive criticisms. I am sure your insights would be appreciated there - in the same way I believe your involvement and participation is appreciated and recognised in medical conferences - that's major progress John - from where I come from, and where I grew up (the land that supposedly gave birth to our great western civilisation).
Keep it up, and I hope you don't mind me sharing my thoughts - but we are all making progress. Let us not lose sight of this.
Many thanks, Yanni, and I'm very grateful you're making me defend my position. It keeps me honest and it keeps readers informed. And yes, we do need clinicians all on the same page. I may be extremely critical of the DSM, but the DSM-III in its time was a monumental achievement.
You've given me something to think about, here. If the DSM-5 doesn't display any leadership, then we may well see a return to pre-DSM days where nosology balkanizes into various fiefdoms, where say depression means one thing at one university and different thing entirely at another. We already see bipolar going this way.
I think we already do see this kind of balkanization -- not in diagnosis, but in selection of criteria for clinical trials. Those who want a new medication to get good scores are getting more selective about the subtypes they include in the trial.
As well, when these medications are marketed, in the widest sense of that word (including journal write-ups, case studies, etc.) people cross diagnostic categories, to use medications indicated for one condition to treat another.
Clinicians are already balkanizing. They seem either to be making it up as they go along, depending on their own narrow experience and the last sales rep in their office, or else slavishly following the book and ignoring new research.
Well, the new research is all over the place. There isn't some authoritative body of "the gene people" or "the brain people." There are rather some old classifications and a great deal of research that supports it, more or less, (with a growing awareness of "less.") There are also a lot of people who know we need some new classifications put out there, first to be ridiculed, and then to be explored for how they might account for things that don't really fit under the old classifications.
Seems to me that the proposed DSM V people say it's not their job to lead. It's their job to state the current state. And maybe they are right. They are the institution people. They represent the APA, not the paradigm shifters.
So the system is working the way the system works. Outsiders (read: patients) are going rogue with their ideas. Next, some psychiatrist (probably a bipolar) will put forward the grand scheme, a la Freud or Kraepelin. This person will be mocked. And then we shall see what we shall see.
Hey, Willa. Absolutely! More later ...
Hey, Willa. I'm on a proper keyboard now. Yes, clinicians do seem to be making it up as they're going along. There is a huge lacuna in both leadership and vision, and the brain science and gene science won't come to the rescue for another two decades. Meanwhile, psychiatry is taking an absolute beating. It's so ironic. New scientific advances are truly mind-boggling. Yet uncertainty rules and cynicism is high.
Thank heaven I have you to talk to. :)
But using these criteria, I would be bipolar... and I don't want to be!!
Hey, Gledwood. No, you wouldn't. You would have cycling illness. But here's the bottom line: We don't get to choose which illness we would like to have. Otherwise, we would all choose something easily identifiable that would go away simply by taking a magic pill.
Unfortunately, both patients and clinicians are under the delusion that depression is one of those easily identifiable illnesses that will go away simply by taking an SSRI. Except way too many times it doesn't and often gets worse.
So maybe the depression is something else, which responds to different treatments. And maybe you get better. Your choice ...
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